What is polymyalgia rheumatica (PMR)?

From the Guidelines

Polymyalgia rheumatica should be treated with low-dose oral prednisone, usually 15-20mg daily, which often provides dramatic symptom relief within days, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1.

Key Considerations

• Treatment should aim at the best care and must be based on a shared decision between the patient and the treating physician, taking into account patient perspective and preferences 1.
• Patients should have an individualised PMR management plan, including access to education focusing on the impact of PMR and treatment, as well as advice on individually tailored exercise programmes 1.
• Regular monitoring of symptoms, inflammatory markers (ESR and CRP), and potential steroid side effects is essential, with follow-up visits suggested every 4–8 weeks in the first year, every 8–12 weeks in the second year, and as indicated in case of relapse or as prednisone is tapered and discontinued 1.
• Calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplements are recommended to prevent steroid-induced osteoporosis, and some patients may need bisphosphonates for bone protection 1.
• Steroid-sparing agents like methotrexate may be considered for patients requiring prolonged therapy, as they have been shown to be effective in reducing cumulative glucocorticoid doses and improving remission rates 1.

Prognostic Factors

• Female sex, high erythrocyte sedimentation rate (ESR), and peripheral arthritis have been associated with a higher relapse risk and/or prolonged therapy in some studies, although the evidence is not consistent across all studies 1.
• Patients with these factors may require closer monitoring and more aggressive treatment to prevent relapses and minimize steroid-related side effects.

Treatment Goals

• The primary goal of treatment is to achieve rapid and sustained symptom relief, while minimizing the risk of steroid-related side effects and optimizing quality of life.
• Treatment should be tailored to the individual patient, taking into account their unique needs, preferences, and comorbidities.

From the Research

Treatment of Polymyalgia Rheumatica

• The treatment of polymyalgia rheumatica (PMR) is based on low-dose glucocorticoids, with the goal of inducing remission and preventing relapse 2, 3.
• Patients with isolated PMR typically experience a rapid response to 12.5-25 mg of prednisone per day 3.
• The initial dose of prednisolone can be around 15 mg per day, with a reduction to 7.5-10 mg by 8 weeks 4.
• A maintenance dose of 7.5 mg of prednisolone per day after 6-9 months may be sufficient for most patients 4.
• Steroid withdrawal is possible within 2 years of starting treatment, although some patients may need 4 years or more 4.

Glucocorticoid-Sparing Agents

• Methotrexate is a conventional disease-modifying antirheumatic drug commonly used for disease management, especially for relapses of PMR 5, 2, 3.
• Methotrexate can be used as a steroid-sparing agent, with doses of 7.5-12.5 mg per week 5 or 10 mg per week or higher 2.
• Other biologic agents, such as tocilizumab, have shown efficacy in PMR, but controlled trials are needed to fully establish their effectiveness 3.

Treatment Duration and Relapse

• The duration of treatment with corticosteroids can vary, with some patients able to withdraw from treatment after a mean of 31 months 6.
• Relapse can occur after withdrawal of treatment, with 30 out of 72 patients relapsing within 21 months of withdrawal 6.
• No clinical feature has been found to predict which patients are more likely to relapse 6.